Abstract
BackgroundTacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease. Tacrolimus is usually prescribed in such situation at a dose of 3.0 mg/day. Pneumocystis pneumonia induced by this dose of tacrolimus has been reported in many cases; however, we encountered a rare case of Pneumocystis pneumonia induced by low-dose tacrolimus and methylprednisolone.Case presentationWe herein report the case of an 82-year-old Asian Japanese female with rheumatoid arthritis and Pneumocystis pneumonia who was being treated with low-dose tacrolimus and low-dose methylprednisolone therapy. She was diagnosed with rheumatoid arthritis at 52 years of age and was administered oral low-dose methylprednisolone and salazosulfapyridine. Her condition had been stable under this treatment for 30 years. However, her arthralgia worsened three months before admission. The salazosulfapyridine was changed to tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared. She was admitted to our hospital for Pseudomonas pneumonia, and her symptoms improved almost completely with intravenous ceftazidime therapy. However, on the 14th day of admission, she developed acute respiratory failure due to Pneumocystis pneumonia and died on the 17th day of admission in spite of adequate treatment.ConclusionOur report highlights the importance of providing prompt prevention, diagnosis and treatment of Pneumocystis pneumonia in rheumatoid arthritis patients under tacrolimus and low-dose methylprednisolone therapy.
Highlights
Tacrolimus is an immunosuppressive drug used to prevent acute rejection following organ transplantation and to treat autoimmune disease
The laboratory test values on the 14th day of admission were as follows: white blood cells, 5270/μL with a left shift; lymphocytes, 210/μL; serum lactate dehydrogenase (LDH), 315 IU/L; serum C-reactive protein (CRP), 25.8 mg/dL; Krebs von den Lungen-6 (KL-6) level, 457 IU/L; surfactant protein-D (SP-D), 358 ng/mL; plasma (1 → 3) beta-D-glucan level, 716 pg/dL, which was high compared with the data obtained before this admission (17 pg/mL)
Et al reported a case of progressive interstitial pneumonia associated with amyopathic dermatomyositis refractory to cyclosporine that was successfully treated with tacrolimus [1]
Summary
Tacrolimus is an immunosuppressive drug often administered to prevent acute rejection following organ transplantation and to treat autoimmune diseases (e.g., rheumatoid arthritis (RA), polymyositis/dermatomyositis and ulcerative colitis (UC)) and atopic dermatitis. The salazosulfapyridine was changed to low-dose tacrolimus (0.5 mg/day) by her physician, and her arthralgia almost completely disappeared Her initial vital signs were as follows: body temperature, 38.0°C; blood pressure, 132/74 mmHg; heart rate 96 beats/minute; respiratory rate, 22 breaths/minute; and oxygen saturation (SpO2) on room air, 82%. The laboratory test values on the 14th day of admission were as follows: white blood cells, 5270/μL with a left shift; lymphocytes, 210/μL; serum LDH, 315 IU/L; serum CRP, 25.8 mg/dL; Krebs von den Lungen-6 (KL-6) level, 457 IU/L (normal, < 500 IU/L); surfactant protein-D (SP-D), 358 ng/mL (normal, < 110 ng/mL); plasma (1 → 3) beta-D-glucan level, 716 pg/dL (normal, < 11 pg/mL), which was high compared with the data obtained before this admission (17 pg/mL). The patient’s sputum was positive for Pneumocystis jirovecii according to polymerase chain reaction (PCR) She was immediately treated with sulfamethoxazole/trimethoprim (ST) at a dose of 10 mg/kg per day and high-dose mPSL (1 g/day for 3 days) with empirical antibiotic therapy (ciprofloxacin). Her respiratory status rapidly deteriorated and she died on the 16th day of admission
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